Given the poverty of many in Rwanda, these low premiums still price out a significant slice of the population. The government of Rwanda is committed to equitable health services and Dr. Binagwaho says, "Whatever we do, we make sure that the poorest and most vulnerable have benefits too. We do not just do things for people who can access healthcare normally." After finding that the utilization of health care lagged in the poorest fifth of the population, in 2010 the government began to subsidize premiums and co-payments for those living in extreme poverty through the support of The Global Fund to Fight AIDS, Tuberculosis, and Malaria. For Rwanda, health equity is both a matter of ethics and epidemiology: Access to health care for all citizens is a prerequisite for controlling diseases such as HIV -- and for continued economic growth to lift more Rwandans out of poverty.
Just as the Ministry of Health responded to research on health utilization by cutting for the poorest, Rwanda bases all health policies on available health data. Dr. Binagwaho explains that, "You will not succeed in bringing up a strategy or policy that is not backed up by evidence" -- policies not justified by robust data are rejected. The government relies on what Dr. Farmer calls "burden and gap analysis," first looking at what problems cause the most ill health and then identifying the areas where an affordable, effective intervention can fill the gap. The goal of this analysis is to ensure that every dollar goes as far as possible. As Rwanda brings infectious diseases under control, non-communicable diseases make up an increasing share of burden of disease.
In 2011, for example, Rwanda seized upon the new Gardasil vaccine to inoculate its populace against cervical cancer, the leading cause of cancer in women. Providing all three doses of the vaccine posed a challenge in rural areas, but Rwanda's robust system of primary care and thousands of community health workers supported the effort that reached 93 percent of eligible girls.
To further reduce the impact of cervical cancer, Rwanda has integrated the vaccine with increased programs in screening to catch the disease earlier and improve treatment outcomes for women with cervical cancer. Now, with the HPV vaccination program rolled out, the government of Rwanda looks to improve care for those with cancer by expanding comprehensive cancer treatment program into district hospitals as well as Partners in Health's new Butaro Cancer Center of Excellence -- the country's first dedicated cancer hospital. By making scientific certainty central to policy planning, Rwanda addresses coming challenges and ensures the efficiency and efficacy of proposed programs.
For Syria and Mali, Haiti and Yemen, Rwanda's rebuilding should offer hope that they, too, can remake their countries and recover from crises in the coming decades. While the specific context of Rwanda cannot be replicated, Dr. Farmer contends that Rwanda's focus on evidence-based policy, central planning, health systems, and equitable access to care should be heeded both by countries looking rebuild their health system and those with strong systems already in place. "In our commitment to understanding complexity," said Farmer, "we need to not forget that there are generalizable lessons to delivering care that are not acceptable to ignore."
While the United States still exceeds Rwanda in most traditional health metrics (such as life expectancy), and its hospitals and medical care surpass those in Rwanda, U.S. health outcomes still falter because too many patients fall through the cracks. The U.S. health system relies too heavily on doctors and hospitals to provide care. A growing body of research suggests that more frequent health care use and higher costs may lead to poorer health.
Farmer believes that, if the United States extended health care into the community like Rwanda, care for chronic diseases would markedly improve while costs would over time drop. Indeed, community-based pilots in the United States have proven effective in settings from inner-city Boston to rural Mississippi. Innovations in resource-squeezed places like Rwanda give hope that health care can be both equitable and affordable.